Healthcare Provider Details

I. General information

NPI: 1780497503
Provider Name (Legal Business Name): JOHN BLAKE ENDRIS FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 LENOX CT
JACKSON MS
39211-4145
US

IV. Provider business mailing address

383 CLARKDELL RD
CANTON MS
39046-9465
US

V. Phone/Fax

Practice location:
  • Phone: 601-421-3280
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number907149
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907149
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: